Regulating internal pressure of a cryotherapy balloon catheter

ABSTRACT

A method of performing a cryotherapy procedure can include introducing a cryotherapy balloon catheter at a treatment site inside a patient&#39;s body; regulating, during a first phase of a cryotherapy procedure, flow of cryogenic fluid to and exhaust from a distal balloon portion of the cryotherapy balloon catheter to cause an initial pressure to be maintained inside the distal balloon portion that is sufficiently high to cause an outer wall of the distal balloon portion to be pressed against body tissue at the treatment site; and regulating, during a second phase of the cryotherapy procedure, flow of cryogenic fluid to and exhaust from the distal balloon portion to cause a) a temperature inside the distal balloon portion to reach a value sufficient to deliver therapeutic levels of cryotherapy to the body tissue, and b) a second-phase pressure to be maintained that is within a threshold value of the initial pressure.

CROSS REFERENCE TO RELATED APPLICATION

This application is a continuation of U.S. application Ser. No.12/129,046, filed May 29, 2008, now U.S. Pat. No. 8,187,261, thedisclosure of which is incorporated herein by reference.

BACKGROUND

A number of serious medical conditions may be treated in a minimallyinvasive manner with various kinds of catheters designed to reachtreatment sites internal to a patient's body. One such medical conditionis atrial fibrillation—a condition that results from abnormal electricalactivity within the heart. This abnormal electrical activity mayoriginate from various focal centers of the heart and generallydecreases the efficiency with which the heart pumps blood. It isbelieved that some of these focal centers reside in the pulmonary veinsof the left atrium. It is further believed that atrial fibrillation canbe reduced or controlled by structurally altering or ablating the tissueat or near the focal centers of the abnormal electrical activity.

One method of ablating tissue of the heart and pulmonary veins to treatatrial fibrillation is cryotherapy—the extreme cooling of body tissue.Cryotherapy may be delivered to appropriate treatment sites inside apatient's heart and circulatory system by a cryotherapy catheter. Acryotherapy catheter generally includes a treatment member at its distalend, such as an expandable balloon having a cooling chamber inside. Acryogenic fluid may be provided by a source external to the patient atthe proximal end of the cryotherapy catheter and delivered distallythrough a lumen to the cooling chamber where it is released. Release ofthe cryogenic fluid into the chamber cools the chamber (e.g., throughthe Joule-Thomson effect), and correspondingly, the balloon's outersurface, which is in contact with tissue that is to be ablated. Gasresulting from release of the cryogenic fluid may be exhaustedproximally through an exhaust lumen to a reservoir or pump external tothe patient.

SUMMARY

Some cryotherapy procedures involving a cryotherapy balloon catheterinclude two phases. In a first phase of the cryotherapy procedure, theballoon portion of the cryotherapy balloon catheter can be initiallypositioned at a treatment site inside a patient. A small volume ofcryogenic fluid can be delivered to inflate the balloon portion againstbody tissue that is to be treated during a second phase of cryotherapy.In the second phase of the cryotherapy procedure, a larger volume ofcryogenic fluid can be delivered in order to lower the temperature ofthe balloon and the adjacent body tissue that is to be treated. In boththe first and second phases, pressure inside the balloon can becontrolled such that it remains at a substantially constant value. Insome implementations, maintaining a substantially constant pressureinside the balloon prevents the balloon from moving away from thetreatment site after it is initially positioned.

In the cryotherapy balloon catheter, cryogenic fluid can be delivered tothe balloon portion through a supply lumen, and released inside theballoon portion, where it undergoes a phase change that cools theballoon portion by the Joule-Thomson effect. Gas resulting from thecryogenic fluid being released and changing phase inside the chamber canbe exhausted through a separate exhaust lumen. The pressure inside theballoon portion can be controlled by regulating one or both of a rate atwhich cryogenic fluid is delivered and a rate at which the exhaust isextracted.

In some implementations, a method of performing a cryotherapy procedureincludes introducing a cryotherapy balloon catheter at a treatment siteinside a patient's body; regulating, during a first phase of acryotherapy procedure, flow of cryogenic fluid to and exhaust from adistal balloon portion of the cryotherapy balloon catheter to cause aninitial pressure to be maintained inside the distal balloon portion thatis sufficiently high to cause an outer wall of the distal balloonportion to be pressed against body tissue at the treatment site; andregulating, during a second phase of the cryotherapy procedure, flow ofcryogenic fluid to and exhaust from the distal balloon portion to causea) a temperature inside the distal balloon portion to reach a valuesufficient to deliver therapeutic levels of cryotherapy to the bodytissue, and b) a second-phase pressure to be maintained that is within athreshold value of the initial pressure.

The threshold value may be, for example, substantially 10% of theinitial pressure, substantially 5% of the initial pressure, orsubstantially 0.5 pounds per square inch absolute (PSIA). The initialpressure may be in the range of 10-20 pounds per square inch absolute(PSIA).

Regulating during the first phase may include regulating flow ofcryogenic fluid to and exhaust from the distal balloon portion of thecryotherapy balloon catheter such that a temperature on the outer wallis maintained that does not substantially cool the body tissue beyondits nominal temperature. In some implementations, regulating during thesecond phase includes regulating flow of cryogenic fluid to and exhaustfrom the distal balloon portion of the cryotherapy balloon catheter suchthat the temperature on the outer wall is sustained at 80° C.+/−10° C.In some implementations, regulating during the second phase includesregulating flow of cryogenic fluid to and exhaust from the distalballoon portion of the cryotherapy balloon catheter such that a quantityof heat can be removed that is sufficient to circumferentially ablatepulmonary vein tissue of an average human adult to a depth of 5 mmwithin five minutes.

The method may further include regulating, after the second phase, flowof cryogenic fluid to and exhaust from the distal balloon portion suchthat minimal heat is extracted from the body tissue, to allow the bodytissue to warm up. The method may further include at least partiallydeflating the distal balloon portion, introducing the cryotherapyballoon catheter to a second treatment site, and regulating the flow ofcryogenic fluid to and exhaust from the distal balloon portion to repeatthe first and second phases of the cryotherapy procedure at the secondtreatment site. Regulating flow of cryogenic fluid to and exhaust fromthe distal balloon portion may include regulating flow of liquid nitrousoxide to the distal balloon portion and flow of gaseous nitrous oxidefrom the distal balloon portion.

In some implementations, a cryotherapy catheter includes an elongatemember and an inflatable balloon at a distal end of the elongate member,the elongate member having lumens formed therein to supply cryogenicfluid to a chamber of the balloon and to channel exhaust from theballoon chamber; and a controller programmed to control a first rate atwhich the cryogenic fluid is supplied to the balloon chamber and asecond rate at which exhaust is channeled from the balloon chamber. Thecontroller can be programmed to a) develop, during a first phase of acryotherapy procedure, a first pressure inside the balloon chamber, at atemperature that is substantially equal to a nominal temperature of anouter wall of the inflatable balloon, and b) maintain, during a secondphase of the cryotherapy procedure, a pressure inside the balloonchamber that is within a threshold value of the first pressure, at atemperature that is sufficiently low to extract heat, at a therapeuticrate, from an environment adjacent to the outer wall.

In some implementations, a diameter of the elongate member may be sizedsuch that inflatable balloon can be routed, in a deflated state, to theleft atrium of an adult human patient. The inflatable balloon may beconfigured to deliver, when inflated, cryotherapy to an ostium or antrumof a human patient's pulmonary vein. In some implementations, theinflatable balloon is configured to deliver cryotherapy to a humanpatient's prostate.

The cryotherapy catheter may further include a guidewire andcorresponding guidewire lumen. A diameter of the guidewire lumen may beminimized, and a cross-sectional area of an exhaust lumen configured tochannel exhaust from the balloon chamber may be maximized to maximize apossible vacuum force at a chamber end of the exhaust lumen.

The inflatable balloon may comprise a compliant material configured toenable the balloon to inflate under a pressure of 0.5 pounds per squareinch (PSI) or less above an ambient pressure that is adjacent to andoutside the inflatable balloon. The inflatable balloon may comprise anouter balloon and inner balloon that is separate from the outer balloon,wherein the inner balloon defines the chamber.

The details of one or more implementations are set forth in theaccompanying drawings and the description below. Other features,objects, and advantages will be apparent from the description anddrawings, and from the claims.

BRIEF DESCRIPTION OF DRAWINGS

FIGS. 1A and 1B illustrate details of an example cryotherapy ballooncatheter that can be used to deliver cryotherapy to body tissue in firstand second treatment phases, respectively.

FIGS. 2A-2D illustrate additional example details of the cryotherapyballoon catheter that is shown in FIGS. 1A and 1B.

FIGS. 3A, 3B and 3C illustrate example rate v. time, temperature v. timeand pressure v. time diagrams corresponding to operation of the cathetershown in FIGS. 1 and 2A-2D.

FIG. 4 is a flow diagram illustrating an example method of controllingpressure and temperature in a balloon catheter.

Like reference symbols in the various drawings indicate like elements.

DETAILED DESCRIPTION

Some cryotherapy procedures involving a cryotherapy balloon catheterinclude two phases. In a first phase of the cryotherapy procedure, theballoon portion of the cryotherapy balloon catheter can be initiallypositioned at a treatment site inside a patient. A small volume ofcryogenic fluid can be delivered to inflate the balloon portion againstbody tissue that is to be treated during a second phase of cryotherapy.In the second phase of the cryotherapy procedure, a larger volume ofcryogenic fluid can be delivered in order to lower the temperature ofthe balloon and the adjacent body tissue that is to be treated. In boththe first and second phases, pressure inside the balloon can becontrolled such that it remains at a substantially constant value. Insome implementations, maintaining a substantially constant pressureinside the balloon prevents the balloon from moving away from thetreatment site after it is initially positioned. In this context, asubstantially constant value can include, for example, values that varyby 25% or less, 10% or less, 5% or less, 0.5% or less, etc.; and“substantially” can, for example, refer to “within 25%,” “within 10%,”“within 5%,” “within 0.5%,” etc.

In the cryotherapy balloon catheter, cryogenic fluid can be delivered tothe balloon portion through a supply lumen, and released inside theballoon portion, where it undergoes a phase change that cools theballoon portion by the Joule-Thomson effect. Gas resulting from thecryogenic fluid being released and changing phase inside the chamber canbe exhausted through a separate exhaust lumen. The pressure inside theballoon portion can be controlled by regulating one or both of a rate atwhich cryogenic fluid is delivered and a rate at which the exhaust isextracted.

FIGS. 1A and 1B illustrate example details of a cryotherapy ballooncatheter 100 that can be used to deliver cryotherapy. FIGS. 1A and 1Bfurther depict an example first treatment phase (FIG. 1A) and secondtreatment phase (FIG. 1B) in which the cryotherapy can be delivered.Additional details of the example cryotherapy balloon catheter 100 aredescribed below with reference to FIGS. 2A-2D.

The cryotherapy balloon catheter 100 of FIGS. 1A and 1B has a distalcryotherapy balloon 103 that can be inserted into a body lumen of apatient, such as, for example, a blood vessel or other internal bodystructure. More particularly, for example, the distal cryotherapyballoon 103 can be inserted (in a deflated state), through appropriateblood vessels, into a patient's heart, and specifically into thepatient's left atrium (e.g., through the femoral vein, inferior venacava, right atrium, trasseptal wall and into the left atrium). Once inthe patient's left atrium, the cryotherapy balloon can be employed toablate tissue of the pulmonary veins (e.g., tissue at the ostium orantrum of one or more pulmonary veins) in order to eliminate aberrantelectrical signals that may be causing atrial fibrillation in thepatient. Similarly, the cryotherapy balloon catheter 100 can be routedto other treatment sites inside a patient and employed to treat otherconditions, such as cancer of the prostate. During whatever treatment isperformed, a proximal end 106 of the cryotherapy balloon catheter 100remains outside the patient.

Between the proximal end 106 and the distal cryotherapy balloon 103 isan elongate member 109 (e.g., a catheter shaft) having various internallumens, including a supply lumen 112 for delivering a cryogenic fluid tothe distal cryotherapy balloon 103. The cryogenic fluid can be releasedinto a chamber 115 of the balloon 103, where it undergoes a phase changeto a gas. As a result of the phase change, heat is extracted from thesurroundings of the chamber 115, thereby cooling the surface 118 of theballoon 103 and body tissue 121 that is in contact with the surface 118(e.g., via the Joule-Thomson effect). The elongate member 109 includesan exhaust lumen 124 for exhausting the resulting gas from the chamber115.

During an example first phase of a cryotherapy procedure, depicted inFIG. 1A, the balloon 103 is positioned at a treatment site and inflatedagainst body tissue 121 (e.g., a patient's pulmonary vein). To inflatethe balloon, cryogenic fluid can be delivered at a low flow rate to theballoon chamber 115 (e.g., at a rate RATE_(1A)), and exhaust can bechanneled out of the chamber 115 at a corresponding low flow rate (e.g.,at a rate RATE_(2A)).

The flow rates of cryogenic fluid into the chamber 115 and exhaust outof the chamber 115 can be controlled such that a pressure inside thechamber 115 (P_(INITIAL)) is developed that is sufficient to push theouter surface 118 of the balloon 103 against the body tissue 121 that isto be treated. Volume of the cryogenic fluid that is delivered to thechamber can be minimized, such that little heat is extracted from thebody tissue 121. That is, the cryogenic fluid can be delivered in thefirst phase primarily to develop the initial pressure necessary toinflate the balloon, rather than to cool the balloon 103 and tissueadjacent to the balloon.

During an example second phase of a cryotherapy procedure, depicted inFIG. 1B, a relatively larger volume of cryogenic fluid can be suppliedto the chamber 115 in order to cool the surface of the balloon 118(e.g., via the Joule-Thomson effect) and thereby extract heat from theadjacent body tissue 121 at a therapeutic rate (e.g., a rate at which adesired amount of tissue is cooled to a therapeutically low temperature,such as −10° C. to −90° C.). As depicted in FIG. 1B, regions 127 of bodytissue can be cooled by the larger volume of cryogenic fluid, as thatcryogenic fluid changes phase to a gas.

The higher flow rate of cryogenic fluid (e.g., RATE_(1B)) in the secondphase can be balanced by a correspondingly higher flow rate of exhaust(e.g., RATE_(2B)), such that the pressure inside the chamber 115 duringthe second phase (P_(SECOND) _(—) _(PHASE)) is very close to the initialpressure (e.g., within a threshold value, Δ, such that P_(SECOND) _(—)_(PHASE)=P_(INITIAL)+/−Δ). In some implementations, the threshold value,Δ, is a relatively small percentage of the initial pressure, such as 1%or less, 5%, 10%, 25%, etc.

Regulating the flow of cryogenic fluid to and exhaust from the distalballoon portion 103 such that internal pressures in the first and secondphases are substantially constant (e.g., within a threshold value, Δ, ofeach other) may reduce the likelihood that the balloon portion 103 willmove relative to tissue that is to be treated inside a patient. If thepressure is not controlled in this manner, the balloon 103 may, in someimplementations, become dislodged from its initial position if and whenpressure inside the balloon changes significantly. This can beespecially true in some implementations in which the tissue to betreated is in a natural state of movement during the treatmentprocedure. For example, in the case of cryotherapy treatment involving apatient's pulmonary veins, cryotherapy is typically delivered when thepatient's heart is beating and the ostia of the pulmonary veins are alsomoving with each beat. By maintaining the pressure inside the balloonportion at a relatively constant value between initial positioning andtreatment phases, the balloon portion may be less likely to becomedislodged from its initial location than if the pressures between theinitial positioning phase and the treatment phase are not activelycontrolled. Moreover, the balloon portion 103 may be less likely tobecome dislodged during the initial stages of the treatment phase, whenthe balloon portion 103 may have started to freeze to the body tissue.Minimizing movement at this point can be particularly important to avoidtearing the body tissue being treated.

Additional details of the example cryotherapy catheter 100 are nowdescribed with reference to FIGS. 2A-2D. As described above, thecryotherapy catheter 100 includes an elongate member 109 that has aninflatable balloon 103 at a distal end 206. The balloon 103 has aninternal chamber 115 to which cryogenic fluid is delivered to cool theinternal chamber 115, the external surface 118 of the balloon 103, andadjacent body tissue. A port device 202 is attached to a proximal end204 of the elongate member 109. The port device 202 provides connectionsto various external equipment, including a cryogenic fluid source 230and an exhaust pump 227.

The catheter's internal lumens allow cryogenic fluid to be delivereddistally from the external cryogenic fluid source 230 to the internalchamber 115 of the balloon 103. In addition, the internal lumens of theelongate member 109 allow exhaust resulting from delivery of cryogenicfluid to the internal chamber 115 of the balloon 103 to be deliveredproximally from the internal chamber 115 to the external exhaust pump227. During operation, there may be continuous circulation within theelongate member 109 of cryogenic fluid distally and exhaust proximally.

A controller 228 can regulate flow of cryogenic fluid to the internalchamber 115 of the balloon 103 (“the balloon 103” in portions of thedescription that follow) and flow of exhaust from the balloon. Inparticular, for example, the controller 228 can, in one implementationas shown, regulate a valve 229 that controls flow of the cryogenic fluidfrom the cryogenic fluid source 230. The cryogenic fluid source 230 canbe, for example, a pressurized flask of cryogenic fluid, such as nitrousoxide or another suitable cryogenic fluid. In other implementations (notshown), the controller controls a pump and/or pump valve combination todeliver cryogenic fluid to the internal chamber of the balloon.Similarly, the controller 228 can regulate a valve 231 and/or vacuumpump 227 to regulate flow of exhaust from the balloon 103.

By controlling both the rate at which cryogenic fluid is delivered tothe balloon 103 and the rate at which exhaust is extracted from theballoon 103, the controller 228 can develop and maintain a pressureinside the balloon 103 at a number of different temperatures. Forexample, when cryogenic fluid is delivered at a very low rate to theballoon 103, and exhaust is similarly extracted at a very low rate, theballoon 103 may be inflated, but very little heat (if any) may beextracted from the balloon 103 or from body tissue that is in contactwith the balloon. As another example, when cryogenic fluid is deliveredat a higher rate, a greater amount of heat can be extracted from theballoon 103 and from body tissue that is in contact with the balloon.Varying the rate at which exhaust is extracted from the balloon 103relative to the rate at which the cryogenic fluid is supplied to theballoon can control the pressure. In particular, for example, for agiven rate at which the cryogenic fluid is supplied to the balloon 103,extracting exhaust at a higher rate will generally result in a lowerpressure inside the balloon, and extracting exhaust at a lower rate willgenerally result in a higher pressure inside the balloon.

To precisely control pressures or flow rates, the controller 103 canemploy either or both of open- or closed-loop control systems. Forexample, in some implementations, a rate at which cryogenic fluid (e.g.,the position of the valve 229) is delivered to the balloon can becontrolled with an open-loop control system, and a rate at which exhaustis extracted from the balloon 103 (e.g., the position of the valve 231or force exerted by the pump 227) can be controlled with a closed-loopcontrol system. In other implementations, both rates can be controlledby closed-loop control systems.

In a closed-loop control system, some feedback mechanism is provided.For example, to control the rate at which cryogenic fluid is supplied tothe balloon 103, the controller 228 can employ one or more pressuresensors, such as pressure sensors P1 and P2 on either side of thecontrol valve 229. In such an arrangement, sensor P1 can be employed toconfirm an adequate supply of cryogenic fluid, and sensor P2 can beemployed for closed-loop control of the supply valve 229. The controller228 can be programmed to control a flow rate of cryogenic fluid based onthe pressure measured by sensor P2 and further based on a size andresistance to flow of a supply lumen (e.g., supply lumen 212, shown inFIG. 2B). In other implementations, the controller 228 can employ bothpressure sensors P1 and P2 to obtain a differential pressuremeasurement, and the controller can use the differential pressuremeasurement to control flow of cryogenic fluid to the balloon 103.

Additional sensors can be employed to regulate flow of exhaust (e.g.,exhaust gas resulting from cryogenic fluid changing state inside theballoon 103) out of the balloon 103. Indirectly, such regulated flow ofexhaust out of the balloon 103, in combination with the regulated flowof cryogenic fluid into the balloon, can control the pressure inside thechamber 115. In particular, the controller 228 can employ one or morepressure sensors, such as, for example, a pressure sensor P3 inside thechamber 115 and/or a pressure sensor P4 at the proximal end of anexhaust lumen (e.g., exhaust lumen 224).

A cryotherapy catheter may employ additional sensors. For example, thecryotherapy catheter 100 is depicted as having a fifth pressure sensor,P5, between an internal balloon 221 that forms the chamber 115 and anexternal balloon 103 that comes into contact with body tissue that is tobe treated. Such a two-layer or two-balloon approach may provide asafety benefit. In particular, for example, if either the internalballoon 221 or external balloon 103 is compromised, cryogenic fluid andgas inside the balloons can be isolated from the patient's body. In someimplementations, the fifth sensor can indicate whether both internalballoon 221 and external balloon 103 are intact. In suchimplementations, a vacuum can be drawn between the balloons 221 and 103,such that the surfaces of the two balloons may be in contact undernormal conditions. Under normal conditions, sensor P5 may typicallydetect a pressure corresponding to a fixed vacuum. If the inner balloon221 bursts, the pressure sensor P5 may detect a positive pressure; ifthe outer balloon 103 bursts, the pressure sensor P5 may detect less ofa vacuum than before the outer balloon 103 burst. Various other pressuresensors (not shown) may be employed in other implementations.

Pressure sensors P1-P5 are graphically depicted at points correspondingto where pressure may be measured. Physically, a pressure sensor (ortransducer) can disposed in the catheter 100 where depicted, andelectrical signals from the sensor or transducer can be routed toappropriate equipment at the proximal end 204 of the catheter 100.Alternatively, one or more pressure transducers can be disposed at theproximal end 204 of the catheter 100, and the transducers can be fluidlycoupled to points at which a pressure measurement is desired (e.g.,points corresponding to the depicted locations in FIG. 2A) by pressurelumens (not shown). Other pressure sensor or transducer arrangements arecontemplated.

Individual pressure sensors can measure pressure in different ways. Insome implementations, each sensor measures absolute pressure, forexample, in pounds per square inch absolute (PSIA). In suchimplementations, two pressure sensors may typically be used to obtain adifferential measurement that inherently eliminates any effect of localatmospheric pressure (e.g., ambient pressure). For example, if P1 and P2are absolute pressure sensors in the catheter 100, the controller 228can employ both P1 and P2 to differentially determine a pressure in thesupply lumen 212. In other implementations, each pressure sensor maymeasure pressure relative to an ambient pressure (e.g., a pressureoutside and generally adjacent to the patient, or put another way, theatmospheric pressure next to the patient, given the patient's altitudeand relevant atmospheric conditions of the air surrounding the patient),which may itself be measured a separate sensor (not explicitly shown).Another sensor may be employed to measure ambient pressure at one ormore points inside the patient's body (e.g., to compensate for bloodpressure or other internal pressures).

In some implementations, as mentioned above, pressure inside the balloon103 can be primarily controlled by controlling the rate at which exhaustis extracted from the balloon 103. Temperature inside the balloon 103,on the other hand, may depend on control of both the flow of cryogenicfluid and the flow of exhaust. That is, for a given pressure inside theballoon, a larger amount of cryogenic fluid supplied, and correspondingamount of exhaust removed may result in a lower temperature on thesurface 118 of the balloon 103, than would result from a smaller amountof cryogenic fluid being supplied to the balloon 103 with acorresponding smaller amount of exhaust removed from the balloon tomaintain the same pressure.

The controller 228 itself can take many different forms. In someimplementations, the controller 228 is a dedicated electrical circuitemploying various sensors, logic elements and actuators. In otherimplementations, the controller 228 is a computer-based system thatincludes a programmable element, such as a microcontroller ormicroprocessor, which can execute program instructions stored in acorresponding memory or memories. Such a computer-based system can takemany forms; include various input and output devices; and may beintegrated with other system functions, such as monitoring equipment 242(described in more detail below), a computer network, other devices thatare typically employed during a cryotherapy procedure, etc. For example,a single computer-based system may include a processor that executesinstructions to provide the controller 228 function, display imaginginformation associated with a cryotherapy procedure (e.g., from animaging device); display pressure, temperature and time information(e.g., elapsed time since a given phase of treatment was started); andserve as an overall interface for a medical practitioner who uses thecryotherapy catheter 100. In general, various types of controllers arepossible and contemplated, and any suitable controller 228 can beemployed.

The catheter 100 shown in FIG. 2A is an over-the-wire type catheter.Such a catheter 100 employs a guidewire 212, extending from the distalend 206 of the catheter 100. In some implementations, the guidewire 212may be pre-positioned inside a patient's body. Once the guidewire 212 isproperly positioned, the balloon 103 (in a deflated state) and theelongate member 109 can be routed over the guidewire 212 to a treatmentsite. In some implementations, the guidewire 212 and balloon portion 103of the catheter 100 may be advanced together to a treatment site insidea patient's body, with the guidewire portion 212 leading the balloon 103by some distance (e.g., several inches). When the guidewire portion 212reaches the treatment site, the balloon 103 may then be advanced overthe guidewire 212 until it also reaches the treatment site. In overthe-wire implementations, as shown, the cryotherapy catheter 100includes a guidewire lumen 213, which allows the balloon 103 to berouted to a treatment site inside a patient over a pre-positionedguidewire (see, for example, FIG. 2C). Other implementations arecontemplated, such as steerable catheters that do not employ aguidewire. As depicted in one implementation, the catheter 100 includesa manipulator 236, by which a medical practitioner may navigate theguidewire 212 and balloon 103 through a patient's body to a treatmentsite.

In some implementations, release of cryogenic fluid into the coolingchamber can inflate the balloon 103 to a shape similar to that shown inFIG. 2A. In other implementations, a pressure source 224 can be used toinflate the balloon 103 independently of the release of cryogenic fluidinto the internal chamber 115 of the balloon 103. The pressure source224 may also be used to inflate an anchor member on the end of theguidewire 212 (not shown).

The catheter 100 includes a connector for connecting monitoringequipment 242. The monitoring equipment may be used, for example, tomonitor temperature or pressure at the distal end of the catheter 100.

To aid in positioning the treatment member 103 of the catheter 100inside a patient's body, various marker bands 233 can also be disposedat the distal end 206 of the catheter 100. The marker bands 233 may beopaque when the catheter is viewed by x-ray or other imaging techniques.

In some implementations, the balloon 103, and a corresponding separateinternal cooling chamber, if present (e.g., balloon 221, shown in FIG.2A), may be formed from a polymer including, but not limited to,polyolefin copolymer, polyester, polyethylene teraphthalate,polyethylene, polyether-block-amide, polyamide, polyimide, nylon, latex,or urethane. For example, certain implementations of the balloon 103comprise PEBAX® 7033 material (70D poly ether amide block). The balloon103 may be made by blow-molding a polymer extrusion into the desiredshape. In some implementations, the balloon 103 may be constructed toexpand to a desired shape when pressurized without elastically deformingsubstantially beyond the desired shape.

A number of ancillary processes may be used to affect the materialproperties of the balloon 103. For example, a polymer extrusion may beexposed to gamma radiation which can alter the polymer infrastructure toprovide uniform expansion during blow molding and additional burststrength when in use. In addition, the molded balloon 103 may be exposedto a low temperature plasma field which can alter the surface propertiesto provide enhanced adhesion characteristics. Those skilled in the artwill recognize that other materials and manufacturing processes may beused to provide balloon 103 (and any internal balloon(s)) suitable foruse with the catheter 100.

FIG. 2B shows a longitudinal cross-section of the example cryotherapyballoon 103 and an example elongate member 109 through which cryogenicfluid and exhaust can be cycled to and from the internal chamber 115 ofthe cryotherapy balloon 103. As depicted in FIG. 2B, cryogenic fluid canbe delivered from an external source (e.g., 230 in FIG. 2A) to a coolingchamber 115 internal to the balloon 103, via a coolant delivery lumen112. The coolant can be released into the cooling chamber 115 from anopening at the end of the delivery lumen 112, or the coolant can bereleased through a cryotherapy device 219 (see FIG. 2D) disposed at theend of the delivery lumen 112. In implementations in which it ispresent, the cooling device 219 can include a coiled extension 235having a number of apertures 237 from which pressurized liquid coolantcan escape and change state to a gas. When released, the coolant canundergo a phase change, cooling the chamber 115 via the Joule-Thomsoneffect, as well as cooling the external surface 118 of the outermostballoon 103 and a patient's body tissue that is adjacent to the externalsurface 118 of the outer balloon. The cryogenic fluid, or gas if thefluid has undergone a phase change, can then be exhausted through anexhaust lumen 224 to a reservoir, pump or vacuum source external to thecatheter (e.g., 227 in FIG. 2A). In some implementations, the exhaustlumen 224 can be defined generally by the outer layer of the elongateshaft 109, as shown. In other implementations, the catheter can includeone or more dedicated exhaust lumen structures (not shown) that aredefined independently of the elongate member 109.

The coolant that is cycled into the balloon 115 is typically one thatwill provide the appropriate heat transfer characteristics consistentwith the goals of treatment. In some implementations, liquid N₂O(nitrous oxide) can be used as a cryo coolant. When liquid N₂O is used,it can be transported to the cooling chamber 115 in the liquid phasewhere it changes to a gas at the end of the coolant delivery lumen 112,or from the apertures 237 of a cooling device 219. Other implementationsmay use Freon, Argon gas, and CO₂ gas, or other agents as coolants.

In some implementations, as shown and briefly described above, a secondballoon 221 is provided within the outer balloon 103 to isolate thecryogenic fluid within the cooling chamber 115. In such implementations,the outer balloon 103 forms a safety chamber that prevents coolant fromescaping if the cooling chamber 115 balloon 821 bursts. A separatevacuum lumen (not shown) may be provided to evacuate any gas or liquidthat escapes from the internal cooling chamber 115. In operation, theouter and inner balloons 103 and 821 may expand and deflate together. Insome implementations, release of coolant inflates the balloons 103 and821. In some implementations, the balloons 103 or 821 are first inflatedby the injection of an inflation fluid or gas (e.g., a saline solutionor an inert gas), after which the coolant may be introduced to thecooling chamber 115.

FIG. 2C shows a radial cross-section along the line A-A that is shown inFIG. 2B. As shown in FIG. 2C, the coolant delivery lumen 212 is adjacentto the guidewire lumen 213, and the guidewire lumen 213 is shown to besubstantially coaxial with the exhaust lumen 224, which corresponds tothe overall shaft (e.g., elongate member 109) of the catheter. In someimplementations, the cross-sectional area of the exhaust lumen 224 ismaximized, to permit the greatest possible vacuum at the chamber. Tomaximize the area, the guidewire lumen 213 can be minimized or omitted,and other unnecessary lumens can be omitted. By maximizing thecross-sectional area and resulting maximum possible vacuum force at thechamber 115 of the balloon 103, pressure inside the balloon may, in someimplementations, be more easily controlled. Moreover, with a compliantballoon material (see additional detail below), the pressure inside theballoon during different phases of cryotherapy treatment can beminimized to only a fraction of a PSI over ambient pressure, which mayfurther reduce the possibility that the balloon will become dislodgedfrom its initial position.

In some implementations, lumens can have other arrangements, and more orfewer lumens can be included in the catheter. For example, the coolantdelivery lumen 212 may be disposed coaxially around the guidewire lumen213; the guidewire lumen 213 may be omitted in a steerable catheterdesign; lumens for steering members may be provided; one or more vacuumlumens may be included; one or more exhaust lumens may be included thatare independent of the outer layer of the catheter shaft 109; additionallumens may be provided for inflating or deflating the balloons 103 or221 or for inflating or deflating other balloons not shown in FIG. 2A,2B or 2C; and additional lumens may be provided to control an anchormember that may be disposed on a guidewire near the distal portion ofthe balloon 103.

FIGS. 3A, 3B and 3C illustrate rate v. time, temperature v. time andpressure v. time diagrams corresponding to operation of the catheter 100shown in FIGS. 1 and 2A-2D, according to one example implementation. Inall three figures, a time period 301 depicts a preliminary phase, duringwhich the balloon catheter 100 can be positioned at a treatment siteinside a patient; a time period 304 depicts a first phase, during whichthe balloon portion 103 of the catheter 100 is inflated against tissueto be treated; and a time period 307 depicts the second phase of anexample cryotherapy procedure, during which cryotherapy can be deliveredto appropriate body tissue while the internal pressure of the balloon103 can be maintained at a relatively constant level.

As depicted in FIG. 3A, rates at which cryogenic fluid is supplied tothe balloon 103 during the preliminary phase (period 301) aresubstantially zero. That is, as the balloon portion 103 of the catheter100 is positioned, the balloon 103 is generally deflated. In someimplementations, in addition to being deflated, the balloon may beenclosed by an introducer sheath or other structure of the catheter 100.The flow of exhaust out of the balloon is also substantially zero,although a slight vacuum may be drawn in some implementations in orderto ensure that the balloon 103 remains deflated during the initialpositioning phase. During this time, as depicted in FIG. 3B, temperatureof the balloon 103 is substantially equal to the nominal bodytemperature of the patient (e.g., 37° C.).

The pressure inside the balloon, as depicted in FIG. 3C, is typicallyzero during the preliminary stage, or slightly negative (in cases inwhich a slight vacuum is drawn), relative to the environment external tothe balloon. The environment external to the balloon can include, forexample, atmospheric pressure at the patient and/or internal pressureadjacent to the balloon 103 and inside the patient. In absolute terms,this pressure may translate to 15-17 PSIA—for example, in an environmentin which atmospheric pressure is 14.7 PSIA and internal blood pressureadds another one or two PSIA.

At the beginning of the first phase, during the initial portions of timeperiod 304, flow of cryogenic fluid can be started, as depicted in FIG.3A, and a corresponding flow of exhaust from the balloon 103 can also bestarted. As described above, the primary purpose of this first phase canbe to inflate the balloon 103 against body tissue that is to be treated.Thus, as depicted in FIG. 3C, pressure inside the balloon 103 increasesrelative to the pressure in the preliminary phase. This pressure may bea few PSI above the pressure outside and adjacent to the balloon. Thus,when the balloon 103 is positioned inside the heart of a patient at sealevel, the pressure necessary to inflate the balloon may be in the rangeof 14.7 to about 20 PSIA, or in differential terms relative to theambient pressure, 0.25 PSI or less, to about 5 PSI.

The pressure needed to inflate the balloon can depend on the materialused to form the balloon. For example, very compliant materials canenable a balloon to be inflated by relatively low pressures, whilestiffer balloon materials may require greater inflation pressures. Insome implementations, more compliant balloons are advantageous. Inaddition to inflating under lower pressures, more compliant balloons maymore readily conform to irregularly shaped internal structures of thepatient, which may result in more efficient delivery of cryotherapy.

During the first phase, the temperature inside the balloon 103 may dropslightly, as depicted in FIG. 3B, since some heat is inherentlyextracted from the surrounding environment when liquid cryogen changesphase to a gas. In many implementations, however, the flow of liquidcryogen is maintained at a low enough level that the amount of heatextracted is very minimal, resulting in at most a small temperature droprelative to the nominal temperature (e.g., 0.5° C., 1° C., 5° C., etc.).

In FIG. 3A, flows of cryogenic fluid to the balloon 103 and exhaust fromthe balloon are depicted as being continuous. In some implementations,the balloon 103 is inflated in a different manner. For example, theballoon 103 can also be inflated by introduction of a small, discreteamount of cryogenic fluid. Some of the resulting gas can be exhausted,and some of the resulting gas can be left in the balloon 103 in order tomaintain the pressure inside the balloon 103. Other flow rate profilesare possible, and any suitable flow rate profile that maintains thedesired pressure and temperature can be employed.

During the second phase (e.g., the treatment phase of a cryotherapyprocedure), volume of cryogenic fluid delivered to the balloon 103 canbe increased, as depicted in FIG. 3A, in order to treat (e.g., cool orfreeze) body tissue that is adjacent to the balloon. As depicted in FIG.3B, temperature during the second phase drops to a cryogenicallytherapeutic temperature. More specifically, heat from the adjacent bodytissue is absorbed by the process undergone by the cryogenic fluid as itchanges state to a gas, and this extraction of heat results in the bodytissue being cooled or frozen.

Turning briefly to the physiology of cryotherapy, different therapeuticresults can be achieved by different levels of cooling. For example,with respect to treating atrial fibrillation by remodeling tissue of thepulmonary veins (e.g., permanently altering the electrical structure orcharacteristics), it may be desirable to bring tissue over the fullthickness of the portion of the pulmonary vein being treated to −20° C.A typical human pulmonary vein may have a thickness in the range of 1-5mm, so a physician may deliver cryotherapy to the pulmonary vein untilit is expected that the entire thickness has reached the desiredtemperature (e.g., −20° C.). The temperature of −20° C. is merelyprovided as an example. Some tissue can be remodeled, or partiallyremodeled, at a higher temperature, such as −10° C., but the physicianmay treat beyond the temperature at which remodeling begins in order toincrease the efficacy of the treatment. Other kinds of tissue can beremodeled or otherwise treated at different temperatures.

At higher temperatures (e.g., −5° C., 0° C., 5° C., or some otherhypothermic value), a temporary, reversible change in the body tissuemay occur. For example, with respect to the aberrant electrical pathwaysthat can give rise to atrial fibrillation, tissue through which theelectrical pathways form can be chilled to a temperature that does notpermanently remodel the tissue but that temporarily disrupts theelectrical pathways. This chilling, which may be referred to ascryomapping, can be used to confirm that remodeling of the intendedtreatment site will be efficacious, without causing other adverse sideeffects (e.g., a conduction block in an undesirable location). Followingconfirmation (e.g., through the use of electrical probes and/orstimuli), the tissue can be permanently remodeled by being cooled tolower temperatures (e.g., −10° C., −20° C. or lower temperatures).

The above examples are provided in the context of treating an electricalcondition such as atrial fibrillation. The reader will appreciate,however, that the systems, apparatus and methods described herein can beemployed to treat other conditions. In particular, for example,maintaining pressure inside a cryotherapy balloon between an initialpositioning phase and a treatment phase can provide advantages tovarious cryotherapy procedures, such as procedures to treat prostatecancer or other prostate conditions, or procedures to remodel vein orartery tissue.

As depicted in FIG. 3C, pressure inside the balloon 103 during thesecond phase 307 can be within some threshold (+/−Δ) of the pressureinside the balloon 103 within the first phase 304. That is, as describedabove, the pressure inside the balloon 103 can be maintained at arelatively constant value between the first and second phases, such aswithin 1% or less, within 5%, within 10%, within 25%, etc. Bymaintaining the pressure inside the balloon portion at a relativelyconstant value between initial positioning and treatment phases, theballoon 103 may be less likely to become dislodged from its initiallocation than if the pressures between the initial positioning phase andthe treatment phase are not actively controlled.

In FIG. 3A, the flow rate of exhaust from the balloon 103 is depicted assubstantially tracking the flow rate of cryogenic fluid to the balloon103. The rates may be proportional in many implementations, but thereader will appreciate that the units of flow are typically differentbetween the flow rates of cryogenic fluid to the balloon 103 and theflow rate of exhaust from the balloon 103. That is, when a cryogenicfluid is employed that changes state to a gas inside the balloon 103,the volume occupied by the gas will typically be many times larger thanthe volume occupied by the same amount cryogenic matter in liquid form.Thus, for a cryogenic compound having an expansion rate of 60 (e.g.,where one unit of liquid expands to 60 units of gas), the exhaust flowrate may be 60 times that of the cryogenic flow rate, when a constantpressure is maintained within the balloon. Flow rates may have differentproportions for other cryogenic compounds having different expansionratios (e.g., 1:10, 1:30, 1:100, 1:600, 1:5000, etc.).

FIG. 4 is a flow diagram illustrating an example method 400 ofcontrolling pressure and temperature in the balloon 103. In someimplementations, the method 400 is implemented by the controller 228shown in FIG. 2A. As shown in one implementation, and with reference tothe preceding figures, the method 400 can include various decisionelements that determine whether the balloon 103 is to be inflated (401)or deflated (410), whether a first treatment phase is to be performed(404) or whether a second treatment phase is to be performed (407). Thedecision elements can, in some implementations, be evaluated based onuser input received by the controller 228. For example, during acryotherapy procedure, a physician may provide input to the controller228 (e.g., through a command entered through a user interface of acomputer device, through manual actuation of a switch, etc.) to inflatethe balloon 103 or initiate a particular phase of treatment.

When it is determined (401) that the balloon is to be inflated, thecontroller 228 can regulate (413) flow of cryogenic fluid to the balloonto deliver a small quantity of the cryogenic fluid, or to continuouslydeliver cryogenic fluid at a low flow rate. The rate can be sufficientto inflate the balloon but can be kept low enough to minimize anycooling effect within the balloon. In some implementations, withreference to FIGS. 2A and 2B, the controller 228 can regulate (413) theflow of cryogenic fluid by controlling a valve 229 between a cryogenicfluid source 230 and a cryogenic supply lumen 212. The valve 229 in suchan implementation can be controlled in an open-loop or closed-loopmanner. In closed-loop control scenarios, the controller 228 can employpressure sensors, such as sensors P1 and P2 to control the flow (e.g.,based on a correlation between pressure and mass delivered).Alternatively, the controller 228 can employ other kinds of metering orsensing devices, such as a mass-flow meter to regulate (413) an amountof cryogenic fluid supplied to the balloon 103.

A corresponding flow rate of exhaust from the balloon 103 (e.g., exhaustgas produced when cryogenic fluid is released into and changes state inthe balloon 103) can be regulated (414). The exhaust flow rate can beregulated (414) in a manner that develops a desired pressure inside theballoon 103 (e.g., a pressure necessary to inflate the balloon 103). Forexample, in some implementations, it may be desirable to inflate theballoon with a pressure of 0.25 to about 5.0 PSI above an ambientpressure at a treatment site inside a patient (e.g., a pressurecorresponding to atmospheric pressure and internal blood pressure of thepatient at the treatment site). In absolute terms, that pressure may bein the range, for example, of about 15 PSIA to about 20 PSIA. To developand maintain such a pressure, the controller 228 can employ one or morepressure sensors, such as sensors P3 and P4, or other appropriatemetering or sensor devices.

When it is determined (404) that cryotherapy treatment is to beperformed, the controller 228 can regulate (416) flow of cryogenic fluidto the balloon 103 to deliver a larger flow of the cryogenic fluid—inparticular, a sufficient flow rate to remove a therapeutic quantity ofheat from body tissue being treated. For example, the mass of cryogenicfluid delivered to the balloon 103 may be sufficient to remove enoughheat to freeze a circumferential band of body tissue that is in contactwith the balloon (e.g., tissue corresponding to the ostium or antrum ofa patient's pulmonary vein, in a cryotherapy treatment for atrialfibrillation) to −20° C., and to a depth of 5 mm. The mass of cryogenicfluid delivered to the balloon 103 may be further controlled such thatthe heat is removed within a desired period of time (e.g., for anaverage human patient, adult male patient, adult female patient,adolescent patient, infant patient, etc.), such as within five minutes,four minutes, three minutes, etc. The amount of heat that is to beremoved, and thus the amount of cryogenic fluid that is supplied to theballoon, may vary by procedure. For example, more or less tissue mayneed to be frozen in a cryotherapy procedure to treat prostate cancerthan in a cryotherapy procedure for treating atrial fibrillation.

As described above, the controller 228 can regulate (416) the flow ofcryogenic fluid by controlling the valve 229 between a cryogenic fluidsource 230 and a cryogenic supply lumen 212 in a closed- or open-loopmanner and in conjunction with various pressure sensors, or employingother appropriate metering or sensing devices.

A corresponding flow rate of exhaust from the balloon 103 (e.g., exhaustgas produced when cryogenic fluid is released into and changes state inthe balloon 103) can be regulated (417) such that the pressure insidethe balloon 103 is maintained within a threshold value of the pressureduring the first phase. As described above, the controller 228 cancontrol the exhaust rate with the valve 231, and in conjunction withpressure sensors P3 and P4. Alternatively, the exhaust flow rate couldbe controlled in other ways. For example the controller 228 may directlycontrol a vacuum source 227, and the controller 228 may employ othertypes of sensors in place of the pressure sensors P3 and P4, such as,for example, a mass flow meter (not shown in the figures).

When it is determined (407) that the treatment phase is complete, thecontroller 228 can reduce (419) the flow of cryogenic fluid to theballoon 103—for example back to a rate comparable to that in theinflation phase. The controller 228 can simultaneously reduce (420) theflow rate of exhaust out of the balloon to maintain pressure inside theballoon to within a threshold value of the level in the other phases. Bymaintaining the pressure a substantially consistent value as before, theballoon may remain positioned and inflated at the treatment site.

In some implementations, an additional treatment cycle can then beinitiated. For example, it can sometimes be advantageous to freeze bodytissue that is to be treated, allow the tissue to warm back up (e.g.,close to its nominal temperature, or to some temperature that is higherthan a cryomapping temperature), then treat the tissue again. In suchscenarios, two or more treatment cycles may increase the efficacy of theoverall cryotherapy procedure.

When it is determined (410) that the balloon is to be deflated, anycontinuous flow of cryogenic fluid to the balloon 103 can be stopped(422), and the exhaust flow can also be stopped (423) at an appropriatetime. In some implementations, the cryogenic fluid flow is stoppedbefore the flow of exhaust, in order to draw a vacuum in the balloonthat is sufficient to fully deflate the balloon. After the balloon isdeflated, it can be withdrawn from the patient's body. Alternatively,the balloon could be moved to a different treatment site, re-inflated,and the treatment process can be repeated. In other implementations, theballoon 103 can be moved to one or more other treatment sites withoutbeing fully deflated. In some cryotherapy procedures, such as thoseinvolving atrial fibrillation, it may be advantageous to treat multiplesites (e.g., each of four pulmonary veins that are present in a typicalhuman patient), on or more times, within a single procedure.

A number of implementations have been described. Nevertheless, it willbe understood that various modifications may be made without departingfrom the spirit and scope of this document. Accordingly, otherimplementations are within the scope of the following claims.

1. A method of performing a cryotherapy procedure, the method comprising: introducing a cryotherapy balloon catheter at a treatment site inside a patient's body; during a first phase of a cryotherapy procedure, using a pressure source to inflate a distal balloon portion of the cryotherapy balloon catheter, independently of a release of cryogenic fluid into the distal balloon portion, to expand the distal balloon portion and to cause an initial pressure to be maintained inside the distal balloon portion that is sufficiently high to cause an outer wall of the distal balloon portion to be pressed against body tissue at the treatment site; starting a flow of cryogenic fluid to the distal balloon portion and a corresponding flow of exhaust from the distal balloon portion; and regulating, during a second phase of the cryotherapy procedure, flow of cryogenic fluid to and exhaust from the distal balloon portion to cause a) a temperature inside the distal balloon portion to reach a value sufficient to deliver therapeutic levels of cryotherapy to the body tissue, and b) a second-phase pressure to be maintained that is within a threshold value of the initial pressure.
 2. The method of claim 1, wherein the threshold value is substantially 10% of the initial pressure.
 3. The method of claim 1, wherein the threshold value is substantially 5% of the initial pressure.
 4. The method of claim 1, wherein the initial pressure is in the range of 10-20 pounds per square inch absolute (PSIA).
 5. The method of claim 1, wherein the threshold value is substantially 0.5 pounds per square inch absolute (PSIA).
 6. The method of claim 1, wherein using the pressure source to inflate the distal balloon portion during the first phase comprises regulating flow of inflation fluid to the distal balloon portion of the cryotherapy balloon catheter such that a temperature on the outer wall is maintained that does not substantially cool the body tissue beyond its nominal temperature.
 7. The method of claim 1, wherein regulating during the second phase comprises regulating flow of cryogenic fluid to and exhaust from the distal balloon portion of the cryotherapy balloon catheter such that the temperature on the outer wall is sustained at −80° C.+/−10° C.
 8. The method of claim 1, wherein regulating during the second phase comprises regulating flow of cryogenic fluid to and exhaust from the distal balloon portion of the cryotherapy balloon catheter such that a quantity of heat can be removed that is sufficient to circumferentially ablate pulmonary vein tissue of an average human adult to a depth of 5 mm within five minutes.
 9. The method of claim 1, further comprising regulating, after the second phase, flow of cryogenic fluid to and exhaust from the distal balloon portion such that minimal heat is extracted from the body tissue, to allow the body tissue to warm up.
 10. The method of claim 9, further comprising at least partially deflating the distal balloon portion, introducing the cryotherapy balloon catheter to a second treatment site, and regulating the pressure source and the flow of cryogenic fluid to and exhaust from the distal balloon portion to repeat the first and second phases of the cryotherapy procedure at the second treatment site.
 11. The method of claim 1, wherein regulating flow of cryogenic fluid to and exhaust from the distal balloon portion comprises regulating flow of liquid nitrous oxide to the distal balloon portion and flow of gaseous nitrous oxide from the distal balloon portion.
 12. A cryotherapy catheter comprising: an elongate member and an inflatable balloon at a distal end of the elongate member, the elongate member having lumens formed therein to supply inflation fluid and cryogenic fluid to a chamber of the balloon and to channel exhaust from the balloon chamber; and a controller programmed to control a first rate at which the inflation fluid is supplied to the balloon chamber, a second rate at which cryogenic fluid is supplied to the balloon chamber, and a third rate at which exhaust is channeled from the balloon chamber, wherein the controller is programmed to a) inflate the balloon using a pressure source to deliver inflation fluid to develop, during a first phase of a cryotherapy procedure, a first pressure inside the balloon chamber, and b) deliver cryogenic fluid to the balloon chamber and exhaust from the balloon chamber to maintain, during a second phase of the cryotherapy procedure, a pressure inside the balloon chamber that is within a threshold value of the first pressure, at a temperature that is sufficiently low to extract heat, at a therapeutic rate, from an environment adjacent to the outer wall.
 13. The cryotherapy catheter of claim 12, wherein a diameter of the elongate member is sized such that inflatable balloon can be routed, in a deflated state, to the left atrium of an adult human patient.
 14. The cryotherapy catheter of claim 13, further comprising a guidewire and corresponding guidewire lumen.
 15. The cryotherapy catheter of claim 12, wherein the inflatable balloon comprises a compliant material configured to enable the balloon to inflate under a pressure of 0.5 pounds per square inch (PSI) or less above an ambient pressure that is adjacent to and outside the inflatable balloon.
 16. The cryotherapy catheter of claim 12, wherein the inflatable balloon comprises an outer balloon and inner balloon that is separate from the outer balloon, wherein the inner balloon defines the chamber.
 17. The cryotherapy catheter of claim 12, wherein the inflatable balloon is configured to deliver, when inflated, cryotherapy to an ostium or antrum of a human patient's pulmonary vein.
 18. The cryotherapy catheter of claim 12, wherein the inflatable balloon is configured to deliver cryotherapy to a human patient's prostate.
 19. The cryotherapy catheter of claim 12, wherein the controller is programmed to inflate the balloon independently of delivering cryogenic fluid to the balloon. 